André Alessandro Madrid Perdomo

Background: Minimally invasive oncologic surgery has been developed to minimize abdominal wall trauma using single-port laparoscopy. Nonetheless, in tumors in anatomically difficult areas such as posterior liver segments, the deep pelvis and upper mediastinum issues, there remain concerns over the instrument triangulation, exposure and integrity of the oncological margins. This systematic review critically analyzes the comparative feasibility of access, perioperative safety and oncological adequacy of single-port laparoscopic versus multiport laparoscopic resection of difficult-to-access solid tumors. Methods: A systematic review was carried out based on PRISMA guidelines. Pubmed, scopus, web of science and Cochrane library were searched from 2016 to april 2026 using the terms single-port laparoscopy, multiport laparoscopy, oncological margins and difficult access tumours. Adults that reported oncological or perioperative outcomes of solid tumor resections were eligible to participate in comparative and cohort studies. Cases, pediatric studies and non-oncological procedures were excluded. The outcomes of interest were the R0 resection rates, open surgery conversion, operative time, complication rates and margin width. Findings: Forty-eight studies were included that included randomized controlled trials, propensity-matched cohorts and registry analyses. There was heterogeneous and mainly retrospective evidence. Single-port laparoscopy was found to have R0 resection rates similar to multiport laparoscopy (range 88% to 100%) and less early postoperative pain and length of stay. Nevertheless, single-port methods proved to be more conversion-efficient (up to 35% in extended pancreatic resections) and have smaller parenchymal margins (e.g., 5 mm vs. 9.5 mm in posterosuperior liver segments, p=0.012). Registry data showed that single-port transanal total mesorectal excision was associated with a better sphincter preservation in low rectal cancer without a loss of circumferential resection margin positivity (5.1% vs. 5.4, odds ratio 4.11, p<0.001) which is a niche in which single-port access has an anatomical benefit. Multiport laparoscopy was always associated with better triangulation and lower intraoperative difficulty scores and conversion rates were less than 10% in even complex hepatectomy and pancreatectomy groups. Conclusions: Laparoscopy (single-port) has significant recovery and cosmetic advantages in well-selected patients who have peripherally located tumors. Nevertheless, in lesions in anatomically limited areas where precision of margins and dexterity of the instruments are of paramount importance, multiport laparoscopy is the more dependable platform. The existing evidence has shortcomings in terms of selection bias and lack of long-term oncological follow-up. Evidence-based indications are urgently needed and randomized trials that are high quality and stratified by tumor location and difficulty are needed.

Chronic non-communicable diseases and occupational risk exposures increasingly converge within the modern workforce, particularly in middle-income countries such as Mexico, Colombia, and Ecuador. This review analyzes the integration of Primary Care, Occupational Health, and Surgical Services as a coordinated strategy to strengthen chronic disease prevention and improve functional outcomes among economically active adults. Using a structured scientific framework and evidence from internationally recognized literature, the study examines prevention levels, integration mechanisms, occupational risk pathways, and system-level outcomes associated with coordinated care models. The findings indicate that integrated systems prioritize primary prevention and early detection while maintaining structured referral pathways and return-to-work protocols. Occupational stress, sedentary behavior, ergonomic overload, and sleep disruption were identified as major contributors to cardiometabolic and surgical outcomes. When services operate cohesively, improvements are observed in early disease identification, reduction of preventable surgical complications, decreased disability rates, and enhanced value-based efficiency. The results support a model in which primary care serves as the coordinating hub, occupational health as the preventive operational arm, and surgical services as partners in complication management and functional restoration. The integration of these domains provides a sustainable pathway for reducing morbidity, preserving workforce productivity, and strengthening health system performance in contemporary labor environments.

Advanced perioperative risk stratification in complex abdominal surgery has evolved beyond traditional score-based prediction toward a multidimensional and system-oriented framework. Complex abdominal procedures, including emergency laparotomy, oncologic resections, multivisceral operations, and robotic-assisted interventions, continue to be associated with substantial postoperative morbidity and mortality. While established predictive tools such as ASA, POSSUM, Surgical Apgar Score, and ACS NSQIP remain clinically relevant, their performance varies according to surgical urgency, procedural modality, and patient complexity. Contemporary evidence supports the integration of frailty assessment as an independent determinant of physiologic reserve, strengthening predictive precision beyond conventional comorbidity indices. Additionally, structured perioperative pathways, particularly Enhanced Recovery After Surgery (ERAS) protocols and multimodal prehabilitation programs, demonstrate the capacity to modify predicted risk and improve measurable outcomes. The expansion of robotic-assisted abdominal surgery introduces approach-specific variables, including operative duration, pneumoperitoneum physiology, and institutional learning curves, which may influence complication profiles and model calibration. Emerging machine learning–based prediction models offer enhanced discrimination potential but require careful integration into clinical workflows. In Latin American contexts, including Mexico, Colombia, and Ecuador, adaptation and local validation of internationally derived risk models remain essential to ensure contextual applicability. A multidimensional model that integrates validated indices, frailty evaluation, perioperative optimization strategies, surgical modality considerations, and system-level awareness provides a more comprehensive framework for decision-making in complex abdominal surgery. Such integration transforms perioperative risk assessment into an actionable instrument aimed at improving patient-centered outcomes.

Modern surgical practice unfolds in environments characterized by uncertainty, time pressure, technological complexity, and high clinical stakes. Within these conditions, cognitive load emerges as a critical determinant of surgical judgment and intraoperative decision-making. This integrative review synthesizes interdisciplinary evidence from cognitive neuroscience, human factors engineering, and surgical education to examine how mental workload influences performance stability, error vulnerability, and adaptive reasoning during high-risk procedures. The reviewed literature consistently demonstrates that increased cognitive load is associated with performance degradation, particularly when stress amplifies attentional demands and working memory capacity is exceeded. Expertise moderates this relationship by promoting automaticity and efficient cognitive resource allocation; however, even experienced surgeons remain susceptible to overload under unstable or unfamiliar conditions. Measurement methodologies—including subjective workload scales, physiological indicators, behavioral proxies, and neurophysiological signals—reflect ongoing efforts to operationalize cognitive strain within clinical environments. Simulation-based training, deliberate practice frameworks, team communication protocols, and cognitive offloading strategies are repeatedly described as mechanisms capable of enhancing decision stability under pressure. The findings suggest that cognitive load should be conceptualized as a modifiable patient safety variable rather than an unavoidable byproduct of surgical complexity. Integrating cognitive science principles into surgical training and workflow design may strengthen adaptive decision-making and reduce preventable errors. These implications are particularly relevant for diverse international healthcare systems, including those with heterogeneous institutional resources, where optimizing cognitive performance can contribute meaningfully to operative reliability and patient safety.

Minimally invasive and robotic-assisted surgery has evolved into a defining component of contemporary operative care, reshaping technical performance, institutional organization, and health system strategy. This review analyzes the clinical impact, ethical implications, and structural transformation associated with robotic integration in surgery, synthesizing high-impact literature across randomized trials, systematic analyses, implementation research, innovation frameworks, and economic evaluations. Evidence indicates that robotic platforms offer measurable advantages in selected high-complexity procedures, particularly in anatomically confined surgical fields, while demonstrating heterogeneous benefits across broader procedural categories. The distribution of evidence highlights a strong emphasis on technological evolution and operational implementation, with comparatively fewer long-term randomized comparative trials. Economic analyses reveal context-dependent cost-effectiveness, closely linked to procedural volume and institutional capacity. Ethical and regulatory considerations, including accountability, algorithmic transparency, and informed consent adaptation, emerge as increasingly relevant as AI-assisted functionalities expand. In middle-income healthcare systems such as those of Mexico, Colombia, and Ecuador, robotic adoption reflects both technological advancement and structural challenges related to sustainability and equitable access. The findings support the importance of structured innovation governance, particularly staged evaluation models, to ensure responsible diffusion. Robotic-assisted minimally invasive surgery should therefore be understood not solely as a technical enhancement, but as a multidimensional transformation requiring coordinated clinical, economic, and regulatory alignment.